PATIENT CARE NETWORK OF OKLAHOMA (PCNOK) Oklahoma Healthcare Authority ABD Care Coordination RFI Response August 17, 2015

Patient Care Network of Oklahoma Care coordination network of 20 Federally Qualified Health Centers (FQHCs) Serve over 160,000 patients Operate over 50 primary care sites in 77 counties Patient Centered Medical Homes that currently target chronically ill and medically complex patients Strategic investment in infrastructure including Electronic Health Records, Health Information Exchange (connectivity to MyHealth), and data analytics and performance measurement (i.e. SoonerVerse) 2

FQHCs in Oklahoma 3

4 Medical and Mental Health Mobile Services Dental Optometry Pharmacy

FQHCs are Uniquely Positioned “Many FQHCs and CHCs are uniquely positioned to coordinate care for dual-eligible beneficiaries because they provide primary care, behavioral health services, and care management services, often at the same clinic site.” The Medicare Payment Advisory Commission: June 2013 Report to the Congress: Medicare and the Health Care Delivery System 5

6 FQHCs are Well Located

FQHCs: Comprehensive Services / Patient Centered Care 7 Oral Health Care Behavioral Health Medical Care Medications Patient Education Enabling Social Services Eye care Lab, X-Ray, Ultra-sound

FQHC: Care Model for Complex Patients 8 Integrated Delivery Model Data Driven Patient Centered Better Outcomes………AND Lower Costs

Proposed Model: Care Coordination led by Patient Centered Medical Homes Develop an Accountable Care Organization structure that will manage the cost and quality outcomes of the target population through a managed fee-for-service payment mechanism Employ a care coordination model that includes local, dedicated care managers to work with the highest complexity patients Through investments from the State, establish a robust technology and data infrastructure for the creation of statewide care coordination and claims-based risk assessments and interventions 9

Proposed Model: Care Coordination led by Patient Centered Medical Homes 10

Best Practices for Complex Patients High-contact, on the ground intensive care management Focus on coordinating communication across provider care settings (i.e. hospitals, primary care, social service agencies) Leverage community-based resources, including FQHCs Many FQHCs are uniquely positioned to coordinate care for dual-eligible beneficiaries because they provide primary care, behavioral health services, and care management services, often at the same clinic site Source: The Medicare Payment Advisory Commission: June 2013 Report to the Congress: Medicare and the Health Care Delivery System 11

Proposed Model: Flexibility and Scalability Builds upon existing community based, managed FFS pilots already underway in Oklahoma Leverages existing infrastructure among FQHCs Allows for flexibility and innovation over time Risk sharing models could change as model matures PCNOK can interact with a variety of payers Model can expand to include patients beyond Duals Includes proven best practices of approaches in other states that target Duals and other high-need patients 12

Financial Model Overview Maintenance of the payment relationship between SoonerCare and Medicare as payers; PCNOK FQHCs maintain all base, contracted services within the current covered benefits and services. Tiered PBPM payment based on acuity to the PCNOK to cover the cost of the Care Management function. “Shared Savings” payments paid to the PCNOK, and correspondingly shared to the Health Centers. Quality measures that demonstrate no use of “care rationing” to achieve cost goals. No impact on patient’s right to choose where to seek care or payment terms to providers outside of the PCNOK. Alignment with State and Federal Regulations. 13

Financial Model Assumptions 14 Tier LevelDefinitionPercentage of ABD patients Care Coordinator Staffing Ratios PBPM Payment to PCNOK Tier 1: Highest Need 5 or more chronic conditions OR… Severe mental illness 20%1:100$90 PBPM Tier 23-4 chronic conditions OR… 1-2 chronic conditions and mental illness 30%1:200$45 PBPM Tier 31-2 chronic conditions AND… Poor social determinants of health 40%1:500$20 PBPM Tier 4: Lowest Need 0 chronic conditions AND… no mental illness AND… stable social determinants 10%N/A$0 PBPM 1 1 Although no PMPM is paid, in this case the FQHC may bill allowable care coordination CPT codes when services are rendered. For patients for whom a PBPM is paid, no additional care coordination CPT codes may be billed.

Financial Model Overview, cont. Please note: Represents a Y1 patient population of 5,926 that grows to 10,084 by the end of Y5 Represents 25.4 care managers in Y1 and 44 care managers by the end of Y5 Net savings are before shared savings are distributed to PCNOK 15

Efficient, Effective, Patient-Centered 16 Out Patient Care Specialty Care Social Services Hospital Admission

QUESTIONS 17